Childhood adversity in association with personality disorder dimensions: New findings in an old debate

Background

Various studies have reported a positive relationship between child maltreatment and personality disorders (PDs). However, few studies included all DSM-IV PDs and even fewer adjusted for other forms of childhood adversity, e.g. bullying or family problems.

Method

We analyzed questionnaires completed by 512 participants of the ZInEP epidemiology survey, a comprehensive psychiatric survey of the general population in Zurich, Switzerland. Associations between childhood adversity and PDs were analyzed bivariately via simple regression analyses and multivariately via multiple path analysis.

Results

The bivariate analyses revealed that all PD dimensions were significantly related to various forms of family and school problems as well as child abuse. In contrast, according to the multivariate analysis only school problems and emotional abuse were associated with various PDs. Poverty was uniquely associated with schizotypal PD, conflicts with parents with obsessive-compulsive PD, physical abuse with antisocial PD, and physical neglect with narcissistic PD. Sexual abuse was statistically significantly associated with schizotypal and borderline PD, but corresponding effect sizes were small.

Conclusion

Childhood adversity has a serious impact on PDs. Bullying and violence in schools and emotional abuse appear to be more salient markers of general personality pathology than other forms of childhood adversity. Associations with sexual abuse were negligible when adjusted for other forms of adversity.

Lifetime and 12-month prevalence rates of sub-clinical psychosis symptoms in a community cohort of 50-year-old individuals

Background:

Estimation of prevalence rates of sub-clinical psychosis symptoms can vary considerably depending on the methodology used. Furthermore, discussions are ongoing how prevalence rates may differ across various syndromes.

Method:

We analyzed data from the prospective Zurich Study, assessing sub-clinical psychosis with a semi-structured clinical interview in a community cohort of 50 years old individuals. The higher-order factors of psychosis symptoms were analyzed with confirmatory factor analysis to validate the a priori specified symptom-structure. Further associations were examined with contingency tables and logistic regressions.

Results:

The confirmatory factor analysis was consistent with a structure with four higher-order syndromes. Those different syndromes were labeled “thought disorder” (lifetime prevalence = 10.6%), “ego disorder” (4.8%), “hallucination” (9.7%), and “schizotypy” (28.2%). A strong discrepancy was noted between the 12-month prevalence of any symptoms and those considered to be severe. Twelve-month prevalence rates of distressful syndromes ranged from 0.1% for hallucinations up to 6.6% for schizotypy. The most strongly interrelated syndromes were thought disorder and ego disorder (OR = 12.4).

Conclusion:

Our findings indicate a continuity of sub-clinical psychosis within the general population even though only a small proportion suffers from distressing symptoms. Our analyses showed that the syndromes identified here are similar to those found in full-blown schizophrenia, albeit in an attenuated form.

Low emotion-oriented coping and informal help-seeking behaviour as major predictive factors for improvement in major depression at 5-year follow-up in the adult community

PURPOSE

Given the broad range of biopsychosocial difficulties resulting from major depressive disorder (MDD), reliable evidence for predictors of improved mental health is essential, particularly from unbiased prospective community samples. Consequently, a broad spectrum of potential clinical and non-clinical predictors of improved mental health, defined as an absence of current major depressive episode (MDE) at follow-up, were examined over a 5-year period in an adult community sample.

METHODS

The longitudinal population-based PsyCoLaus study from the city of Lausanne, Switzerland, was used. Subjects having a lifetime MDD with a current MDE at baseline assessment were selected, resulting in a subsample of 210 subjects. Logistic regressions were applied to the data.

RESULTS

Coping styles were the most important predictive factors in the present study. More specifically, low emotion-oriented coping and informal help-seeking behaviour at baseline were associated with the absence of an MDD diagnosis at follow-up. Surprisingly, neither formal help-seeking behaviour, nor psychopharmacological treatment, nor childhood adversities, nor depression subtypes turned out to be relevant predictors in the current study.

CONCLUSIONS

The paramount role of coping styles as predictors of improvement in depression found in the present study might be a valuable target for resource-oriented therapeutic models. On the one hand, the positive impact of low emotion-oriented coping highlights the utility of clinical interventions interrupting excessive mental ruminations during MDE. On the other hand, the importance of informal social networks raises questions regarding how to enlarge the personal network of affected subjects and on how to best support informal caregivers.

Relationship between personality and psychopathology in a longitudinal community study: a test of the predisposition model

BACKGROUND

Mounting evidence supports the notion that personality is crucial in the aetiopathology of common mental disorders, but studies that allow for aetiological conclusions are lacking. The aim of the present study was thus to provide a test of the predisposition model.

METHOD

We analysed data from the Zurich Cohort Study, a 30-year longitudinal epidemiological community study of an adult cohort (n = 591) from 1979 to 2008. Personality was assessed in 1988 with an established personality questionnaire, and psychopathology through seven semi-structured interviews between 1979 and 2008.

RESULTS

On the basis of personality assessment from 1988, used as predictor of subsequent psychopathology (1993-2008), while adjusting for sex and prior mental disorders (1979-1988), neuroticism related significantly with future major depression episodes [odds ratio (OR) = 1.41], anxiety disorders (OR = 1.32) and depression treatment use (OR = 1.41). When participants with a past 10-year history (i.e. 1979-1988) of either major depression, anxiety disorder or depression treatment use were excluded, neuroticism in 1988 still significantly predicted first incidence (i.e. 1993-2008) of major depression episodes (OR = 1.53) and depression treatment use (OR = 1.84).

CONCLUSIONS

The present study provides compelling evidence that the personality trait of neuroticism constitutes an independent risk factor for subsequent major depression episodes and use of respective professional treatments, which serves as a proxy for particularly severe and impairing depression episodes. We therefore advocate that personality traits could provide clinically useful prognostic information when considered carefully.

Mismatch negativity: Alterations in adults from the general population who report subclinical psychotic symptoms

BACKGROUND

Deficits of mismatch negativity (MMN) in schizophrenia and individuals at risk for psychosis have been replicated many times. Several studies have also demonstrated the occurrence of subclinical psychotic symptoms within the general population. However, none has yet investigated MMN in individuals from the general population who report subclinical psychotic symptoms.

METHODS

The MMN to duration-, frequency-, and intensity deviants was recorded in 217 nonclinical individuals classified into a control group (n=72) and three subclinical groups: paranoid (n=44), psychotic (n=51), and mixed paranoid-psychotic (n=50). Amplitudes of MMN at frontocentral electrodes were referenced to average. Based on a three-source model of MMN generation, we conducted an MMN source analysis and compared the amplitudes of surface electrodes and sources among groups.

RESULTS

We found no significant differences in MMN amplitudes of surface electrodes. However, significant differences in MMN generation among the four groups were revealed at the frontal source for duration-deviant stimuli (P=0.01). We also detected a trend-level difference (P=0.05) in MMN activity among those groups for frequency deviants at the frontal source.

CONCLUSIONS

Individuals from the general population who report psychotic symptoms are a heterogeneous group. However, alterations exist in their frontal MMN activity. This increased activity might be an indicator of more sensitive perception regarding changes in the environment for individuals with subclinical psychotic symptoms.

Brain correlates of verbal fluency in subthreshold psychosis assessed by functional near-infrared spectroscopy

The prevalence of subthreshold psychotic symptoms in the general population has gained increasing interest as a possible precursor of psychotic disorders. The goal of the present study was to evaluate whether neurobiological features of subthreshold psychotic symptoms can be detected using verbal fluency tasks and functional near-infrared spectroscopy (fNIRS). A large data set was obtained from the Zurich Program for Sustainable Development of Mental Health Services (ZInEP). Based on the SCL-90-R subscales 'Paranoid Ideation' and 'Psychoticism' a total sample of 188 subjects was assigned to four groups with different levels of subthreshold psychotic symptoms. All subjects completed a phonemic and semantic verbal fluency task while fNIRS was recorded over the prefrontal and temporal cortices. Results revealed larger hemodynamic (oxy-hemoglobin) responses to the phonemic and semantic conditions compared to the control condition over prefrontal and temporal cortices. Subjects with high subthreshold psychotic symptoms exhibited significantly reduced hemodynamic responses in both conditions compared to the control group. Further, connectivity between prefrontal and temporal cortices revealed significantly weaker patterns in subjects with high subthreshold psychotic symptoms compared to the control group, possibly indicating less incisive network connections associated with subthreshold psychotic symptoms. The present findings provide evidence that subthreshold forms of psychotic symptoms are associated with reduced hemodynamic responses and connectivity in prefrontal and temporal cortices during verbal fluency that can be identified using fNIRS.

Sex-related and non-sex-related comorbidity subtypes of tic disorders: a latent class approach

BACKGROUND AND PURPOSE

Recent evidence suggests that there may be more than one Gilles de la Tourette syndrome (GTS)/tic disorder phenotype. However, little is known about the common patterns of these GTS/tic disorder-related comorbidities. In addition, sex-specific phenomenological data of GTS/tic disorder-affected adults are rare. Therefore, this community-based study used latent class analyses (LCA) to investigate sex-related and non-sex-related subtypes of GTS/tic disorders and their most common comorbidities.

METHODS

The data were drawn from the PsyCoLaus study (n = 3691), a population-based survey conducted in Lausanne, Switzerland. LCA were performed on the data of 80 subjects manifesting motor/vocal tics during their childhood/adolescence. Comorbid attention-deficit hyperactivity disorder (ADHD), obsessive-compulsive disorder, depressive, phobia and panic symptoms/syndromes comprised the selected indicators. The resultant classes were characterized by psychosocial correlates.

RESULTS

In LCA, four latent classes provided the best fit to the data. We identified two male-related classes. The first class exhibited both ADHD and depression. The second class comprised males with only depression. Class three was a female-related class depicting obsessive thoughts/compulsive acts, phobias and panic attacks. This class manifested high psychosocial impairment. Class four had a balanced sex proportion and comorbid symptoms/syndromes such as phobias and panic attacks. The complementary occurrence of comorbid obsessive thoughts/compulsive acts and ADHD impulsivity was remarkable.

CONCLUSIONS

To the best of our knowledge, this is the first study applying LCA to community data of GTS symptoms/tic disorder-affected persons. Our findings support the utility of differentiating GTS/tic disorder subphenotypes on the basis of comorbid syndromes.

The role played by depression associated with somatic symptomatology in accounting for the gender difference in the prevalence of depression

PURPOSE

A variety of studies suggest the existence of a distinct phenotype of somatic depression, i.e., depression accompanied by significant somatic symptomatology. Previous research suggests that the gender difference in the prevalence of depression is primarily due to a difference in somatic depression. The aim of this study was to compare the gender difference in the prevalence of somatic depression and of depression not accompanied by significant somatic symptomatology (labelled "pure" depression) in two representative samples, the National Comorbidity Survey-Replication (NCS-R) and the Zurich Study.

METHOD

The gender difference in lifetime somatic depression was compared to that of pure depression based on analyses weighted back to the general population in two representative samples. The NCS-R analyses involved a narrow definition of somatic depression with items from the DSM criteria for depression--appetite, sleep, and fatigue. The analysis of the Zurich study added headaches, body image issues, and breathing difficulties to the criteria and comparison to atypical depression.

RESULTS

In both samples, the gender difference in depressive prevalence was due to a large difference in somatic depression with other phenotypes showing little or no gender difference. The gender differences were found to be due to the somatic symptoms rather than the number of symptoms and were much larger for somatic than for atypical depression.

CONCLUSION

The gender difference in the prevalence of depression results from the higher prevalence among women of a specific phenotype, somatic depression.

Unmet needs in patients with first-episode schizophrenia: a longitudinal perspective

BACKGROUND

This study aimed to identify the course of unmet needs by patients with a first episode of schizophrenia and to determine associated variables.

METHOD

We investigated baseline assessments in the European First Episode Schizophrenia Trial (EUFEST) and also follow-up interviews at 6 and 12 months. Latent class growth analysis was used to identify patient groups based on individual differences in the development of unmet needs. Multinomial logistic regression determined the predictors of group membership.

RESULTS

Four classes were identified. Three differed in their baseline levels of unmet needs whereas the fourth had a marked decrease in such needs. Main predictors of class membership were prognosis and depression at baseline, and the quality of life and psychosocial intervention at follow-up. Depression at follow-up did not vary among classes.

CONCLUSIONS

We identified subtypes of patients with different courses of unmet needs. Prognosis of clinical improvement was a better predictor for the decline in unmet needs than was psychopathology. Needs concerning social relationships were particularly persistent in patients who remained high in their unmet needs and who lacked additional psychosocial treatment.

Firearm suicides and availability of firearms: the Swiss experience

This study aimed to examine the association between the availability of firearms at home, and the proportion of firearm suicides in Switzerland in an ecological analysis. The data series were analysed by canton and yielded a fairly high correlation (Spearman's rho=0.60). Thus, the association holds also at a sub-national level.

Subjective distress predicts treatment seeking for depression, bipolar, anxiety, panic, neurasthenia and insomnia severity spectra

OBJECTIVE

To examine correlates of mental health treatment seeking such as gender, diagnosis, impairment, distress and mastery.

METHOD

Longitudinal epidemiological data from the Zurich Study of common psychiatric syndromes, including unipolar and bipolar depression, panic, anxiety, neurasthenia and insomnia, were utilized. In longitudinal Generalized Estimating Equations, treatment seeking was regressed on measures of subjective distress and impairment, childhood family problems, mastery and number of comorbid diagnoses.

RESULTS

Approximately half of all treated participants across all six syndromes suffered from subthreshold disorders. Meeting full or subthreshold diagnostic criteria was associated with treatment seeking for insomnia. Being female was associated with treatment seeking for depression. The only variable highly and consistently associated with treatment seeking, across all syndromes, was subjective distress. Treated participants reported high levels of distress, work and social impairment in both diagnostic and subthreshold groups.

CONCLUSION

Subjective distress may be a better indicator of treatment seeking than symptom count.

The mental health of female sex workers

OBJECTIVE

There is limited information available about the mental health of female sex workers. Therefore, we aimed to make a comprehensive assessment of the mental status of female sex workers over different outdoors and indoors work settings and nationalities.

METHOD

As the prerequisites of a probability sampling were not given, a quota-sampling strategy was the best possible alternative. Sex workers were contacted at different locations in the city of Zurich. They were interviewed with a computerized version of the World Health Organization Composite International Diagnostic Interview. Additional information was assessed in a structured face-to-face interview.

RESULTS

The 193 interviewed female sex workers displayed high rates of mental disorders. These mental disorders were related to violence and the subjectively perceived burden of sex work.

CONCLUSION

Sex work is a major public health problem. It has many faces, but ill mental health of sex workers is primarily related to different forms of violence.

In-patient suicide--a 13-year assessment

OBJECTIVE

To describe the suicide rates of psychiatric in-patients in the canton of Zurich for the period 1992-2004, and to determine putative risk factors.

METHOD

The data were derived from the psychiatric case register of the canton Zurich. The analyses were based on person-years calculations and standardised mortality ratios. Additional information was assessed via case records.

RESULTS

During the 13-year period the standardised mortality ratio was 48.9. The risk of suicide was particularly high in patients with personality and affective disorders. Most suicides occurred during regular leave periods, despite the fact that clinical assessment had indicated there was no suicide risk for the patient.

CONCLUSION

The suicide risk of in-patients is distinctly higher than in the general population. A better assessment of suicide risk before regular leave periods could lead to a decrease of suicides in in-patient settings, as well as a more rigorous treatment of borderline cases, and of affective and psychotic symptoms.

Impact of Childhood Adversity and Premorbid Personality on the Onset and Course of Major Bipolar Disorder

Background:

Clinical studies have demonstrated the great clinical relevance of long-term depression (LTD). Our study aims to characterise long-term bipolar disorder (LTBP) in comparison with episodic (non-chronic) bipolar major depressive episodes (EBP) on the basis of data from a community sample.

Method:

The Zurich Cohort Study is a prospective study of young adults followed from age 20/21 to 40/41 with six interviews. The stratified sample consisted of two thirds high scorers and one third lower scorers on the Symptom Checklist-90 R (SCL-90-R). LTBP, which was assessed from age 27/28 to 40/41, was defined as threshold or subthreshold depressive syndrome plus hypomanic symptoms, present for more days than not over the past year, plus work or social impairment.

Results:

The cumulative incidence of LTBP was 6.3%, and of episodic BP 15.3%. The two groups did not differ in mean age of onset (13.7 vs. 13.1 years). Age of onset was significantly earlier in subjects with a positive FH of depression and was inversely correlated with the somatisation score of the SCL-90R as assessed at age 19/20. The age of onset increased with increasing levels of childhood family problems in subjects with a positive FH, but decreased in subjects without an FH of depression. Chronic BP was associated with early childhood adversity and low self-esteem and, at a trend-level, with no family history of depression.

Conclusions:

The results are surprising and counter-intuitive, a genetic disposition seeming to be correlated more with periodicity than with chronicity.

Suicide after bereavement: an overlooked problem

BACKGROUND

To examine the effect of time on suicide after bereavement among widowed persons.

METHOD

The data were extracted from Swiss mortality statistics for the period 1987-2005. The time between bereavement and subsequent death, specifically by suicide, was determined by linkage of individual records of married persons. The suicide rates and the standardized mortality ratios in the first week/month/year of widowhood were calculated based on person-year calculations.

RESULTS

The annualized suicide rates in widowed persons were highest in the first week after bereavement: 941 males and 207 females per 100,000. The corresponding standardized mortality ratios were approximately 34 and 19 respectively. In the first month(s) after bereavement, the rates and the ratios decreased, first rapidly, then gradually. Except in older widows, they did not reach the baseline levels during the first year after bereavement.

CONCLUSIONS

The suicide risk of widowed persons is increased in the days, weeks and months after bereavement. Widowed persons are a clear-cut risk group under the aegis of undertakers, priests and general practitioners.

Parsing the clinical phenotype of depression: the need to integrate brief depressive episodes

OBJECTIVE

To expand the concept of recurrent brief depression (RBD) to brief depression (BD) and to test its clinical relevance.

METHOD

Subjects (N = 591) were studied prospectively six times from ages 20/21 to 40/41 years. RBD was defined according to DSM-IV as episodes under 2 weeks with about monthly recurrence and work impairment. BD embraces RBD and brief depressive episodes with a frequency of 1-11 per year.

RESULTS

Pure BD and pure major depressive episodes (MDE) did not differ in treatment rates, family history of mood and anxiety disorders or comorbidity with bipolar spectrum and anxiety disorders but they differed in work impairment, suicide attempt rates and distress self-ratings. The combination of BD + MDE identified a very severe group of MDE, comparable with combined depression (MDE + RBD) and double depression (MDE + dysthymia).

CONCLUSION

Our data argue for the use of BD as a diagnostic specifier for severe MDE. RBD remains an important independent subgroup.

Use of army weapons and private firearms for suicide and homicide in the region of Basel, Switzerland

OBJECTIVES

Switzerland has one of the highest rates of firearm suicides in the world. International studies show a positive correlation between the rate of households with guns and femicides with guns. Because its defense system requires a militia to keep personal firearms at home, Switzerland has a high rate of households with a gun.

METHODS

Records of suicides in the region of Basel between 1992 and 1996 were reviewed. Suicides with either army weapons or private firearms and suicides by other means were compared. Methods and types of homicides that occurred in the region at the same time were also analyzed.

FINDINGS

Firearm suicides were clearly the most frequent means of suicide. They were also used in 30.0% of domestic homicides, although other means were used at similar rates. Firearms for suicide were mainly used by men, especially army weapons. These men were younger, professionally better qualified, and fewer had ever been treated in one of the local state psychiatric services.

DISCUSSION

The use of firearms for suicide, rather than homicide, and particularly of army weapons by young, well-educated men, requires more attention in debates and informed policy regarding access to firearms and suicide prevention in Switzerland.

Barriers to stroke thrombolysis in a geographically defined population

OBJECTIVE

Barriers to thrombolysis are rather assessed for hospitalized stroke patients than among geographically defined populations. In a population-based approach, we assessed (1) the utilization rate of stroke thrombolysis in the community, and (2) the significance of the chosen stroke care provider as a potential barrier to thrombolysis.

METHODS

We performed a databank-based post-hoc analysis, derived from data ascertained in a prospective, population-based stroke study among the permanent residents of the canton Basel-City, Switzerland. For the cohort with an onset assessment interval (OAI) < or =3 h, we compared thrombolyzed with non-thrombolyzed patients concerning demographic variables, the National Institutes of Health stroke scale (NIHSS) score, OAI, risk factors, and the type of stroke care provider. For patients without thrombolysis despite an OAI < or =3 h, barriers to thrombolysis were compiled.

RESULTS

Among 269 patients, 49 had an OAI < or =3 h (18% of all patients and 38% of those 128 patients with exactly known time of onset). Fourteen patients received thrombolysis, amounting to a utilization rate of 5.2% (95% CI 2.9-8.6) for all patients and 29% (95% CI 17-43) for the OAI < or =3-hour cohort. For the latter, thrombolyzed differed from non-thrombolyzed patients in higher NIHSS score and type of stroke care provider, but not in demographic variables, OAI, or risk factors. Fourteen of 40 patients (35%) primarily admitted to the stroke unit received thrombolysis, compared with none of 9 patients primarily treated elsewhere (p < 0.04). In the OAI < or =3-hour cohort, mild or regressing stroke severity (48%), admission to hospitals not offering thrombolysis (20%), computed tomography or laboratory contraindications (17%) and severe comorbidity (14%) were barriers to thrombolysis.

CONCLUSION

In this geographically defined population, every 20th stroke patient received thrombolysis. Only a minority of patients had an OAI < or =3 h, rendering late admission the most common barrier to thrombolysis. In the OAI < or =3-hour cohort, admission to hospitals not offering thrombolysis prompted exclusion from thrombolysis as often as established contraindications. Thus, acute stroke patients should solely be brought to hospitals providing thrombolysis.

The Zurich Study: participation patterns and Symptom Checklist 90-R scores in six interviews, 1979-99

OBJECTIVE

The Zurich study is a longitudinal study in psychiatric epidemiology that started in the late 1970s. The sixth interview in 1999 provides the basis to investigate and update the participation and drop-out patterns of the Zurich subjects.

METHOD

Aside from descriptive analyses, particular attention was paid to the Symptom Checklist 90-R (SCL-90-R), used initially to stratify the Zurich sample.

RESULTS

The initial proportions of high-scorers vs. low-scorers (two-thirds vs. one-third) have not changed significantly in the 367 subjects who participated in the 1999 interview. More detailed analyses indicate a selective and changing dependence of participation/drop-out on health status as measured by the SCL-90 R. In recent interviews drop-out has become more likely in subjects with extremely high SCL scores and in subjects with low SCL scores.

CONCLUSION

Drop-out in the Zurich Study is associated with extreme SCL scores.

Which individuals with affective symptoms seek help? Results from the Zurich epidemiological study

OBJECTIVE

Several factors influence whether individuals with affective disorders seek help. The Zurich cohort study provides an opportunity to explore patient-based factors without confounding with problems of access. This study aims to identify features which predict help-seeking behaviour in symptomatic individuals and to explore failure of help seeking in those who did not.

METHOD

Characteristics of currently symptomatic 40-year-old individuals in a stratified epidemiological sample were tested against help-seeking behaviour using bivariate statistics and logistic regression. Individual predictors were identified and interaction effects tested.

RESULTS

Thirty-one per cent of the 364 subjects sought help in the preceding year. Past treatment and living alone were significantly associated with treatment. Total number of symptoms and several individual symptoms correlated with treatment in the bivariate analyses but regression analysis identified "unfounded self-reproach" and "hopelessness" interacting with social support to predict the best treatment.

CONCLUSION

Social support is strongly protective against needing help in the presence of distressing affective symptoms unless these symptoms become elaborated into conclusions about their meaning and prognostic significance.

[Depression among the elderly in Switzerland]

Data for this analysis came from a cross-sectional study on dementia, depression, and disability conducted in Zurich and Geneva in 1995/96. The random sample stratified by age and gender consisted of 921 subjects aged 65 and more. Based on the Canberra Interview for the Elderly, depression was assessed by means of psychogeriatric assessment scales (PAS) according to DSM-III-R criteria. The number of depressive symptoms (NDS) and the prevalence rate of depression (PRD) were computed for the whole sample as well as according to age and gender. To evaluate the independent effects of age as well as gender with regard to the risk of being depressed, multivariate analyses were conducted. On average, 13% of females vs 8% of males reported having at least one depressive symptom. The PAS yielded 298 (41.8%) subjects without depressive symptoms, 341 (50.2%) with 1-3 symptoms, and 60 (8.0%) with four or more. The average NDS was 1.27 (95% CI 1.16-1.39). For females, NDS values statistically significantly higher than those for males were calculated (1.53, 95% CI 1.35-1.70 vs 1.05, 95% CI 0.90-1.20). The NDS increased significantly with age. Subjects with low education levels and being divorced or widowed had statistically significantly higher NDS values than highly educated, married, or single persons. There were strong positive associations between NDS, dementia, and activities of daily living. Multivariate regression analysis revealed gender - however, not age - as a strong risk factor for NDS. Overall PRD amounted to 8.0% (95% CI 5.7-10.2%). Females had statistically significantly higher PRD values than males (10.4%, 95% CI 7.0-13.9% vs 3.9, 95% CI 2.0-5.9%). The PRD increased substantially with age. After adjustment for other risk factors, multivariate logistic regression analysis confirmed the positive statistically significant association between age, gender, and depression.

[Dementia, depression and activity of daily living as risk factors for falls in elderly patients]

OBJECTIVES

Falls among elderly are a well-recognised public health problem. The purpose of the present study was to explore the relation between dementia, number of depressive symptoms, activities of daily living, setting, and risk of falling.

METHODS

Data for the analysis came from a cross-sectional study about dementia, depression, and disabilities, carried out 1995/96 in Zurich and Geneva. The random sample stratified, by age and gender consisted of 921 subjects aged 65 and more. The interview was conducted by means of the Canberra interview for the Elderly, extended by short questionnaire. The subject was classified as a faller if the subject and/or the informant had reported a fall within the last 12 months prior to the interview. Logistic-regression analysis was used to determine the independent impact of dementia, depressive symptoms, and ADL-score on risk of falling.

RESULTS

The stepwise logistic regression analysis has revealed a statistically significant association between dementia (OR 2.14, 95% CI 1.15-3.96), two resp. three depressive symptoms (OR 1.64, 95% CI 1.04-2.60) as well as four or more depressive symptoms (OR 2.64, 95% CI 1.39-5.02) and the risk of falling. There was no statistically significant relationship between studied risk factors and the risk of being one-time faller. However, we found a strong positive association between dementia (OR 3.92, 95% CI 1.75-8.79), four or more depressive symptoms (OR 3.90, 95% CI 1.55-9.83) and the risk of being recurrent faller. Moreover, residents of nursing homes (OR 8.50, 95% CI 2.18-33.22) and elderly aged 85 or more (OR 2.29, 95% CI 1.08-4.87) were under statistically significant higher risk of sustaining recurrent falls.

CONCLUSIONS

The results of the present study confirm that dementia and depression substantially increase the risk of falling.

How complete is AIDS surveillance in Europe? An eagle eye comparison with mortality data

OBJECTIVES

Preliminary assessment of the adequacy of AIDS surveillance efforts in Europe by comparing data from two official sources-AIDS surveillance and mortality statistics.

METHODS

The study used ENAADS (European Non-Aggregate AIDS Data Set) data compiled by the European Centre for the Epidemiological Monitoring of AIDS in St Maurice, France, and mortality statistics from WHO. As ENAADS provides information about AIDS incidence as well as AIDS mortality, both series were compared with WHO mortality data. Western European countries with more than 1000 adult AIDS cases as of July 1997 were included in the cross country comparative analyses.

RESULTS

AIDS surveillance and mortality statistics in Europe depict four different patterns: (1) high overall concordance (Austria, Italy, Switzerland); (2) concordance between incidence by ENAADS and mortality by WHO, but a delay in mortality reporting in ENAADS (France, Spain); (3) more cases in WHO mortality data than in ENAADS data (Germany, Portugal); (4) more cases in ENAADS data than in WHO mortality data (Sweden, United Kingdom, Greece, Belgium).

CONCLUSIONS

National AIDS surveillance systems in Europe exhibit important differences in terms of completeness and functionality. New challenges such as the introduction of effective but expensive and complex treatments will exert demands on surveillance efforts. Countries with discrepant AIDS and mortality data should try to improve and update their surveillance systems.

[Recording of multiple sclerosis in Swiss cause of death statistics. A 10-year mortality follow-up of the Bern prevalence study]

Based on data from a multiple sclerosis (MS) prevalence study which had been carried out in 1986 in the canton of Berne, Switzerland, a follow-up was performed 10 years later to gather information on mortality in the original study population. The authors used information on residency and death as gathered from municipal offices and, additionally, by record-linkage with the Swiss cause of death statistics. Slightly more than 80% of the cases were identified unequivocally as of January 1996. Among them, 21% of the cases died during the ten-year period; 70% of them have an MS entry in the cause of death statistics, mostly as the main cause of death. A large proportion of the non-identifiable cases appear to be related to mortality; thus, the findings here do not provide a promising basis for certain further analyses. In conclusion, continuous updating of personal data is the only way to avoid loss to follow-up in the carefully assembled prevalence database.

[Epidemiological analysis of accidental falls by the elderly in Zurich and Geneva]

The purpose of the study was to determine the prevalence rate of fallers (PRF%) and fall-related consequences among the elderly according to age, gender and setting. Data derive from a cross-sectional study on dementia, depression and handicaps among the elderly, carried out between 1995 and 1996. Elderly people aged 65 and over living in Zurich or Geneva were considered eligible for the study. By means of the Canberra Interview for the Elderly, 921 subjects' and/or informants' interviews were completed. The subjects were classified as a faller if the subject and/or informant reported a fall in the year prior to the interview. Overall PRF% amounted to 27.8% and was higher to a statistically significant degree among females (30.9%) than males (22.5%). Gender difference in PRF was found only among the non-institutionalized elderly. Age-specific PRF increased significantly with the age of the elderly. However, this increase was observed only among male subjects. 143 subjects (PRF 17.1%) have fallen once and 101 (PRF 9.9%) two or more times. Females showed a substantially higher propensity to recurrent falls (age-adjusted OR 1.86; 95% confidence interval 1.11-3.10). While the risk of suffering two or more falls increased with age, it did not increase among one-time fallers. Residents of nursing homes had significantly higher risk of falling as compared with home-dwelling subjects (age-adjusted OR 2.46; 95% confidence interval 1.04-5.78). Every second fall caused fall-related consequences. 9.1% of all falls led to fall-related fracture. The risk of suffering fall-related consequences depended on neither age nor gender. One third of fallers reported fear of further falling. Falls among the elderly occur often and contribute substantially to morbidity.

Season of birth in amyotrophic lateral sclerosis

While studying birth cohort issues, the authors focused also on the seasons of birth in amyotrophic lateral sclerosis (ALS). The analyses were based on computerized death records of Swiss mortality statistics 1969-1993. The results confirm an excess of births in spring months. They suggest that risk factors in ALS can be acquired very early in life, thus introducing a long latency period.